See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/233872496

Basic principles of laparoscopic appendectomy

Article  in  Medicinski pregled · December 2012

DOI: 10.2298/MPNS1210383D · Source: PubMed

CITATIONS READS

3 831

1 author:

Samir Delibegovic
University Clinical Center Tuzla
69 PUBLICATIONS   765 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Emergencysurgery - Colorectal cancer: Our experience View project

Rizvanovic Nermina View project

All content following this page was uploaded by Samir Delibegovic on 09 February 2014.

The user has requested enhancement of the downloaded file.

Med Pregl 2012; LXV (9-10): 383-387. Novi Sad: septembar-oktobar. 383

PREGLEDNI ČLANCI
REVIEW ARTICLES
University Clinic Center Tuzla Pregledni članci
Department of Surgery Review article
UDK 616.346.2-089.87
DOI: 10.2298/MPNS1210383D

BASIC PRINCIPLES OF LAPAROSCOPIC APPENDECTOMY

OSNOVNI PRINCIPI LAPAROSKOPSKE APENDEKTOMIJE

Samir DELIBEGOVIĆ

Summary Sažetak
Introduction. Laparoscopic appendectomy is one of the simplest Uvod. Laparoskopska apendektomija jedna je od najprostijih
laparoscopic procedures, which is gradually becoming the meth- laparoskopskih procedura koja postupno postaje metoda izbora
od of choice in treatment of acute appendicitis due to its advan- u tretmanu akutnog apendicitisa zbog prednosti nad otvorenom
tages over open appendectomy. In South-Eastern Europe the use apendektomijom. U jugoistočnoj Evropi laparoskopska apen-
of laparoscopic appendectomy is still very limited although it is a dektomija još uvek nije rasprostranjena, premda je često reč o
very simple procedure, suitable for training laparoscopic tech- najprostijoj laparoskopskoj proceduri pogodnoj pri učenju lapa-
niques. Technique of Laparoscopic Appendectomy. This review roskopskih tehnika. Tehnika laparoskopske apendektomije.
article describes the position of the patient and surgical team dur- Ovaj revijalni članak opisuje položaj pacijenta i hirurškog tima
ing laparoscopic appendectomy, position of troacars and working u toku laparoskopske apendektomije, položaj troakara i radnih
instruments which result in expressive cosmetic effect, technique instrumenata koji ima za posledicu izraziti postoperativni koz-
of laparoscopic appendectomy, different ways of securing the metski efekat, tehniku laparoskopske apendektomije i različite
base of appendix. Complications of Laparoscopic Appendecto- načine zbrinjavanja baze apendiksa. Komplikacije laparoskop-
my. This review article describes management of complicated ske apendektomije. Ovaj revijalni članak opisuje postupanje s
appendicitis, and intra- and post-operative complications. Con- komplikovanim apendicitisom te intra i post operativne kom-
clusion. Laparoscopic appendectomy has many advantages over plikacije. Zaključak. Laparoskopska apendektomija ima broj-
open appendectomy. The risk of wound infection is lower, post- ne prednosti nad otvorenom apendektomijom: rizik od infekcije
operative pain is weaker and the hospital stay is shorter. i postoperativni bol su manji, a boravak u bolnici je kraći.
Key words: Laparoscopy; Appendectomy; Appendicitis; Surgi- Ključne reči: Laparoskopija; Apendektomija; Apendicitis; Sta-
cal Staplers; Suture Techniques; Sutures; Intraoperative Compli- pleri; Tehnike šivenja; Šavovi; Intraoperativne komplikacije; Po-
cations; Postoperative Complications stoperativne komplikacije

Introduction agnosis and treatment of appendicitis has changed

since then.
Acute appendicitis is the most frequent abdom- Laparoscopic appendectomy for a non-inflamed
inal disease and requires urgent appendectomy. appendix was first reported in 1983 by the gynecolo-
The first reported appendectomy was performed gist Semm [4]. In 1987 Schreiber reported a laparo-
in 1735 because of a perforated appendix with a scopic assisted appendectomy for the treatment of
stercoral fistula by the military surgeon Claudius acute appendicitis [5]. Since then many reports have
Amyand [1], and the first appendectomy with the been published indicating that laparoscopic appen-
correct preoperative diagnosis was performed by dectomy is safe and feasible in most settings [4–7].
Lawson Tait [2] in 1880. In 1889 McBurney de- Although laparoscopic appendectomy was per-
scribed point tenderness in the right lower abdomi- formed several years before laparoscopic cholecys-
nal quadrant, indicative of appendicitis and popu- tectomy, it has only recently become a common
larized the muscle-splitting incision [3]. laparoscopic procedure. One of the reasons is that
For more than 100 years McBurney’s appendec- classic appendectomy through McBurney’s incision
tomy was the gold standard in the treatment of is a simple, quick and efficient procedure which can
acute appendicitis, and right up until the recent de- be performed by most surgeons. Laparoscopic ap-
velopment of laparoscopic surgery, little in the di- pendectomy, on the other hand, needs some level of
Corresponding author: Prof. dr Samir Delibegović, Univerzitetski klinički centar Tuzla,
75000 Tuzla, Trnovac bb, Bosna i Hercegovina. E-mail: delibegovic.samir@gmail.com
384 Delibegović S. Laparoscopic appendectomy

knowledge of laparoscopic surgery and more ex-

pensive equipment. Possible advantages, such as
fewer infections of wounds, shorter hospital stay,
faster recovery and return to everyday activities,
are most often accompanied by a longer operative
procedure (which is shorter as the number of per-
formed appendectomies rises) and higher costs. The
laparoscopic method has proven advantages in
women with pains in the lower right quadrant, im-
proving diagnostic accuracy, decreasing the number
of negative appendectomies and enabling effica-
cious treatment of gynecological diseases [5].
Laparoscopic appendectomy is a safe procedure in
the pregnant patients in the second trimester [8].
When treating chronic appendicitis, laparoscopic Fig. 2. The dissection and division of the mesoappen-
appendectomy has proven advantages, as well [9]. dix by harmonic scalpel
Slika 2. Zbrinjavanje mezoapendiksa harmonijskim sk-
alpelom

right lower quadrant, at the level of the first 12 mm

port, to provide triangulation (Figure 1). Afterwards,
the abdominal cavity is inspected.
Technique of laparoscopic appendectomy
The end of the appendix is seized for the mesoap-
pendix by a grasper placed through the right lower
abdominal 5 mm port. The mesoappendix is skel-
etized from the top to the base using a harmonic
scalpel placed through the left lower quadrant port
(Figure 2). Various techniques described for dissec-
tion of the mesoappendix include electrocoagulation,
clips, endoloop ligatures or linear intestinal stapler.
After that, an endoloop is introduced through the
Fig. 1. Position of the patient, equipment and surgical team same port, three endoloops are passed over the tip of
Slika 1. Položaj pacijenta, opreme i hirurškog tima the appendix and secured at the base of the appen-
dix. Two ligatures are placed 5 mm part, close to the
The position of the patient and the surgical caecum, and a third tie is placed 1 cm distal to the
team first two. The appendix is transected between the
ties, leaving two loops on the caecum end (Figure
The patient is placed in the supine position, 3). As an alternative method, instead of an endoloop,
combined with the Trendelenburg position and left a linear stapler can be introduced (Figure 4), or three
lateral position (10–15 º, inclined towards the sur- Hem-o-lok clips may be placed [10], size XL (Fig-
geon). The surgeon and an assistant stand on the
left side, and the monitor is on the right side of the
patient (Figure 1).
During operation some surgeons stand between
the patient’s legs, and the assistant stands on the pa-
tient’s left side. The video monitor is placed on the
patient’s right side.
Position of trocars and instruments
The surgical procedure is performed under gene-
ral anesthesia. The bladder is decompressed with a
Foley catheter to avoid injury while inserting the su-
prapubic ports. Pneumoperitoneum is established
with a Veress needle through the umbilicus and then
a laparoscope is introduced. Under direct vision, one Fig. 3. The base of the appendix is secured by two en-
12 mm trocar is inserted into the suprapubic region, a doloops
little to the left, and one 5 mm trocar is inserted in the Slika 3. Baza apendiksa zbrinuta pomoću dva endoloopa
Med Pregl 2012; LXV (9-10): 383-387. Novi Sad: septembar-oktobar. 385

aspects that need to be considered when using dif-

ferent techniques in securing the base of the appen-
dix during laparoscopic appendectomy.
Complicated Appendicitis
Retrocaecal Appendix
If the appendix is not identified during the ini-
tial exploration, the caecum is mobilized sharply
with scissors, electrocautery or harmonic scalpel
along the Told line. Atraumatic bowel graspers are
used for retraction of the caecum - reflecting the
caecal pole up and to the left will expose the appen-
dix. In this location, however, the appendix, espe-
Fig. 4. The base of appendix is secured by a stapler cially the tip, may be covered by adhesions, making
Slika 4. Baza apendiksa zbrinuta pomoću staplera the operation difficult. In that case, retrograde dis-
section should be performed. The trocar placement
ure 5). After resection of the appendix, a sterile is the same as for the usual antegrade resection.
specimen retrieval bag is placed into the abdomen Once the caecum and the base of the appendix have
through a 12 mm suprapubic trocar and the appendix been identified, the appendix can be transected
placed inside. If an exudate is present, a drain is with a stapler or between clips or endoloops.
placed in the pouch of Douglas. In cases of difficult, retrocaecal appendix, arti-
In case of uncomplicated appendicitis it is re- cles published in literature describe ”fingeroscopy”,
commended to secure the base of the appendix by which is a laparoscopic assisted procedure, where
using only one ligature [11], and by only one Hem- mobilization of the appendix is performed with a
o-lok clip in all forms of appendicitis [12]. finger [14], after which laparoscopic appendectomy
The method of securing the base of the appendix is performed.
with Hem-o-lok clip can be recommended as a useful
alternative and speed up the acceptance and use of Gangrenous Appendix
laparoscopic appendectomy in developing countries When the appendix is gangrenous, the anato-
such as countries of South-Eastern Europe. It is espe- my is often obscure. In the area of the caecum or
cially important in countries where resources for sur- in the pelvis an exudate is found. The appendix is
gical training with endoloop are insufficient; moreo- identified with careful blunt dissection, and re-
ver, stapler is very expensive, whilst the application moved in the usual manner.
of Hem-o-lok clips is very simple and can be done by
almost any surgeon without extensive training. Perforated Appendix
It is important to emphasize that moderate post- If the perforation is close to the tip of the appen-
operative inflammatory changes were observed dix, closure with an endoloop is possible. If the per-
with the use of the stapler, and with the He-mo-lok foration is close to the base of the endoloop, ligation
[13], which may have implications on postoperative or stapling of the stump, close to the perforated or
recovery. However, the cost and time of the appli- necrotic areas, may be impossible. The caecum
cation as well as tissue reaction are also some of the should be mobilized adequately and the appendix
removed by applying the stapler across the base ap-
pendix.
Appendicular Abscess
If an appendicular abscess is suspected, the Tren-
delenburg position is avoided to prevent contamina-
tion of the upper abdomen. The abscess is identified
by bluntly dissecting the adherent bowel loops away.
The abscess cavity is aspirated, dried and irrigated;
then the appendectomy is performed as described
above. A drain should be placed in the abscess cavity.
Conversion to Open Procedure
The only absolute contraindication for laparo-
scopic appendectomy is the inability to obtain a
pneumoperitoneum safely under general anesthesia
Fig. 5. The base of appendix secured with two Hem-o- [15]. Insufficient experience with laparoscopic ap-
lok clips (size XL). pendectomy or advanced and complicated appendi-
Slika 5. Baza apendiksa zbrinuta s dva Hem-o-lok citis may be indications for conversion to an open
clipsa (veličina XL)
386 Delibegović S. Laparoscopic appendectomy

procedure. However, with increased experience, firmed postoperatively, its removal by relapa-rosco-
most appendicular conditions can be managed lapa- py is possible [23]. A retained fecalith which is
roscopically. Moreover, most skilled laparoscopic manifested as an intraabdominal abscess is treated
surgeons find that complicated appendicitis can of- like any other abscess [24].
ten be managed better through the laparoscope than Incomplete Appendectomy
through a McBurney incision [15[. The view is bet- Stump appendicitis is a delayed obstruction and
ter, abscesses are more easily identified and treated, inflammation of residual tissue left after an incom-
and the entire abdomen may be explored and lav- plete appendectomy [25]. This is a serious but very
aged. rare complication. However, incomplete appendec-
Nevertheless, a prudent surgeon will occasionally tomy may lead to recurrent appendicitis. Some re-
have to convert a laparoscopic appendectomy into an ports suggest an increased incidence of incomplete
open procedure for various reasons that include the appendectomy with laparoscopy, but most pub-
inability to gain exposure, fear of intestinal injury, in- lished cases appeared after open appendectomy.
ability to recognize the base of the appendix, exten- This complication arises when the appendix is
sive adhesions and uncontrolled bleeding. cut a long way from the base. Poor identification of
the join between the appendix and the caecum ap-
Complications of Laparoscopic Appendectomy pears to play an important role. Following the tae-
nia coli from the caecum to the appendix helps to
Most reports of laparoscopic appendectomy in- identify the base. Alternatively, dissection and li-
dicate a low incidence of intraoperative and post- gation of recurrent branches of the appendicular
operative complications [16-22]. artery help to mark the base of the appendix [26].
It is therefore necessary to treat the join of the base
Bleeding of the appendix with the caecum carefully. This
Bleeding is usually overestimated during lapar- rare complication must be taken into account if a
oscopic procedures because of the magnification patient who has undergone appendectomy has re-
of the camera, but most conversions to open proce- curing symptoms and signs of acute appendicitis.
dure occur for this complication [8]. Aggressive
dissection of the mesoappendix may lead to bleed- Postoperative Abscesses
ing, and it can be from the retroperitoneum, during Postoperative abscesses are uncommon with
dissection of an inflamed, retrocaecal appendix. laparoscopic appendectomy. With improvement of
Careful dissection with control of the mesoappen- camera quality, better lavage and cleaning of the
dix can prevent this complication. Bleeding is not operative field, this complication is rarely seen,
difficult to recognize. Suction, pressure of the site and recent reports have noted a significant de-
of bleeding with an instrument or gauze and an ad- crease in abscesses after laparoscopic appendec-
ditional trocar facilitate identification and control tomy [27]. There are reports of subhepatic and
of the site of bleeding. Control can be achieved by subphrenic abscesses, possibly due to the spread
coagulation, clips, or by an endoloop. In very rare of infected fluid while the patient is in the Trende-
situations conversion to open procedure is needed. lenburg position, but this is an unproven theory.
Abscesses are trea-ted by ultrasound guided punc-
Fecalith ture and drainage, with antibiotic therapy.
This is a rare, but frustrating complication [23].
During dissection of a distended, gangrenous appen- Stump Leak
dix, a fecalith may drop into the peritoneal ca-vity. A stump leak is a very rare complication. It may
Retained fecaliths may cause an intrabdominal ab- be related to excessive coagulation of the stump, cau-
scess. Therefore, fecaliths need to be dealt with care- sing tissue necrosis, or inadequately placed endoloop.
fully and cautiously so that they would not be lost be- It is manifested by a stercoral fistula.
tween the loops of the intestine and the pelvis. Fecat-
liths should be thrown into an endobag and the care- Wound Infection
ful lavage should be performed. This complication Infection of a surgical wound is less frequent
will be found more often as laparoscopic appendec- than in open appendectomy, even in cases of gan-
tomy becomes a more common method in the treat- grenous appendicitis. The reduction in the level of
ment of acute appendicitis [24]. Surgeons should be wound infection has probably been achieved due
aware of this complication in order to treat fecalith to the extraction of the appendix through the port
adequately when recognized intra or postoperatively. or in a plastic bag (endobag).
Gentle treatment of an inflamed, gangrenous
appendix and the use of an endobag prevent this Conclusion
complication. Since an abscess develops in all de-
scribed cases of a dropped fecalith after open ap- Laparoscopic appendectomy is increasingly be-
pendectomy, it is recommended to remove the feca- coming the method of choice in the treatment of
lith when it is established that one has dropped in- acute appendicitis due to its advantages over open
traoperatively. If the presence of a fecalith is con- appendectomy. The risk of wound infection is low-
 Med Pregl 2012; LXV (9-10): 383-387. Novi Sad: septembar-oktobar. 387

er, postoperative pain is milder and the hospital one of the simplest laparoscopic procedures. It re-
stay is shorter. The reasons for unsuccessful pro- quires only five laparoscopic appendectomies to
cedures vary; the most common noted are: the po- acquire efficiency, therefore laparoscopic appen-
sition of the appendix, bleeding and abscess. dectomy could be the first laparoscopic operation
Two conditions make laparoscopic appendecto- during laparoscopy training of surgeons.
my especially difficult: retrocaecal position and the Some of the advantages of laparoscopy are re-
presence of an abscess. Even in these cases, lapar- duced traumatization of tissues and less irritation
oscopy makes the open approach easier, indicating of the bowels, milder postoperative pain, shorter
the exact site of the incision. In cases of generalized hospital stay, faster recovery and return to every-
peritonitis, the laparoscopic method facilitates the day activities, which is especially important for
complete cleansing of the abdominal cavity. patients who wish to return to work. The econom-
In South-Eastern Europe the use of laparoscopic ic importance and implications favoring this ap-
appendectomy is still very limited even though it is proach cannot be ignored.
References
1. Creese PG. The firts appendectomy. Surg Gynecol Ob- chnique (fingeroscopy) for treatment of complicated appendi-
stet. 1953;97:643. citis. J Am Coll Surg. 1999;189:131-3.
2. Herrington JL. The vermiform appendix: its surgical 15. Oddsdottir M, Hunter JG. Laparoscopic approach to
history. Contemp Surg. 1991;39:36-44. suspected appendicitis. In: Arregui ME, Sackier JM, eds. Mi-
3. McBurney. Experience with early operative interferen- nimal access coloproctology. Oxford: Radcliffe Medical Pre-
ce in cases of disease of the vermiform appendix. NY State ss; 1995. p. 103-21.
Med J. 1889;50:676. 16. McAnena OJ, Austin O, O’Connell PR, Hederman WP,
4. Semm K. Endoscopic appendectomy. Endoscopy 1983; Gorey TF, Fitzpatrick J. Laparoscopic versus open appendicec-
15­:59-64. tomy: a prospective evaluation. Br J Surg. 1992;79:818-20.
5. Schreber JH. Early experience with laparoscopic ap- 17. Kum CK, Ngoi SS, Goh PMY, TEkant Y, Isaax JR.
pendectomy in women. Surg Endosc. 1987;1:211-6. Randomized controlled trial comparing laparoscopic and
6. Pier A, Gotz F, Bacher C. Laparosocpic appendectomy open appendicectomy. Br J Surg. 1993;80:1599-600.
in 625 cases: from innovation to routine. Surg Laparosc En- 18. Ortega AE, Hunter JG, Peters JH, Swanstrsom LL, Sc-
dosc. 1991;1:8-13. hirmer B. A prospective, randomized comparison of laparosco-
7. Ludvig KA, Cattey RP, Henry LG. Initial experience with pic appendectomy with open appendectomy. Am J Surg. 1995;
laparoscopic appendectomy. Dis Colon Rectum. 1993;36:463-7. 169:208-13.
8. Samardzic J, Delibegovic S, Latic F, Latic A, Kraljik D. 19. Hansen JB, Smithers BM, Schache D, Wall DR, Miller
Laparoscopic appendectomy is safe procedure in the pregnant BJ, Menzies JL. Laparoscopic versus open appendectomy:
patients in second trimester. Med Arh. 2011;65:125-6. prospective randomized trial. World J Surg. 1996;20:17-21.
9. Pandža H, Čustović S, Čović R, Delibegović S. Lapa- 20. McCall JL, Sharples K, Jadallah F. Systematic review
roscopic treatment of lower abdominal pain related to chronic of randomized controlled trials comparing laparoscopic with
appendicitis. Med Arh. 2008;62:268-70. open appendicectomy. Br J Surg.1997;84:1045-50.
10. Delibegović S, Matović E. Hem-o-lok plastic clips in 21. Moberg AC, Montgomery A. Appendicitis: laparosco-
securing of the base of the appendix during laparoscopic ap- pic versus conventional operation: a study and review of the
pendectomy. Surg Endosc. 2009;23:2851-4. literature. Surg Laparosc Endosc. 1997;7:335-9.
11. Neugebauer EAM, Troidl H, Kum CK, Eypasch E, 22. Fallahzadeh H. Should a laparoscopic appendectomy
Miserez M, Paul A. The EAES clinical practice guidelines on be done? Am Surg. 1998:64(3):231-3.
laparoscopic cholecystectomy, appendectomy, and hernia re- 23. Smith AG, Ripepi A, Stahlfeld KR. Case report: retai-
pair (1994). In: Neugebauer EAM, Sauerland S, Fingerhut A, ned fecalith. Laparoscopic removal. Surg Laparosc Endosc
Millat B, Buess G, eds. EAES Guidelines for endoscopic sur- Percutan Tech 2002;12:441-2.
gery. Berlin, Heidelberg. Springer; 2006. p. 265-89. 24. Strathern DW, Jones BT. Retained fecalith after lapa-
12. Delibegovic S. The Use of a Single Hem-o-lok clip in roscopic appendectomy. Surg Endosc. 1999;13:287-9.
securing the base of the appendix during laparoscopic appen- 25. Liang MK, Helen GL, Marks JL. Stump appendicitis:
dectomy. J Laparoendosc Adv Surg Tech. 2012;22:86-7. a comprehensive review of literature. Am Surg 2006;72:162-6.
13. Delibegovic S, Iljazovic E, Katica M, Koluh A. Tissue 26. Greene JM, Peckler D, Schumer W, Greene EL. In-
reaction to absorbable endoloop, nonabsorbable titanium sta- complete surgical removal of the appendix: its complications.
ples, and polymer Hem-o-lok clip after laparoscopic appen- J Int Coll Surg. 1958:29:141-6.
dectomy. JSLS. 2011;15:70-6. 27. Katkhouda N. Intraabdominal abscess rate after lapa-
14. Katkhouda N, Mason RJ, Mavor E, Campos GM, Ri- roscopic appendectomy. Am J Surg. 2000;180:456-9.
vera RT, Hurwitz MB, et al. Laparoscopic finger-assisted te-
Rad je primljen 11. IV 2012.
Recenziran 8. V 2012.
Prihvaćen za štampu 31. V 2012.
BIBLID.0025-8105:(2012):LXV:9-10:383-387.

View publication stats